The transition from medical student to doctor: perceptions of final year students and preregistration house officers related to expected learning outcomes

Effectiveness of short, personalised student assistantships: an evaluative study across eight London hospitals

OBJECTIVES

Student assistantships are recommended to prepare medical graduates for clinical practice. Traditionally, assistantships have consisted of longer placements, often up to 15 weeks. However, within the constraints of the final year, medical schools need to carefully balance the time required for specialty placements, assessments and the risk of student burnout. We set out to evaluate the effectiveness of shorter, personalised student assistantships.

DESIGN

An evaluative study on the changes in final year student confidence in preparedness for practice after a 3-week assistantship with defined learning objectives and learning needs assessment.

SETTING

Eight hospitals affiliated with Imperial College School of Medicine.

OUTCOMES

Student confidence in 10 learning outcomes including organising ward rounds, documentation, communication with colleagues, communication with patients and relatives, patient handover, practical procedures, patient management, acute care, prioritisation and out-of-hours clinical work.

RESULTS

Two hundred and twenty final year medical students took part in the student assistantship, of whom 208 completed both the pre-assistantship and post-assistantship confidence rating questionnaires (95% completion rate). After the assistantship, 169 (81%) students expressed increased confidence levels in one or more learning objectives. For each individual learning objective, there was a significant change in the proportion of students who agreed or strongly agreed after the assistantship (p<0.0001).

CONCLUSION

Overall, the focused 3-week, personalised student assistantships led to significant improvement across all learning objectives related to preparedness for practice. The use of the pre-assistantship confidence rating questionnaire allowed students to identify and target areas of learning needs during their assistantship.

In pursuit of a better transition to selected residencies: a quasi-experimental evaluation of a final year of medical school dedicated to the acute care domain

BACKGROUND

Medical schools seek the best curricular designs for the transition to postgraduate education, such as the Dutch elective-based final, 'transitional' year. Most Dutch graduates work a mean of three years as a physician-not-in-training (PNIT) before entering residency training. To ease the transition to selected specialties and to decrease the duration of the PNIT period, UMC Utrecht introduced an optional, thematic variant of the usual transitional year, that enables the development of theme-specific competencies, in addition to physicians' general competencies.

METHODS

We introduced an optional transitional year for interested students around the theme of acute care, called the Acute Care Transitional Year (ACTY). This study aimed to evaluate the ACTY by judging whether graduates meet postgraduate acute care expectations, indicating enhanced learning and preparation for practice. In a comprehensive assessment of acute care knowledge, clinical reasoning, skills, and performance in simulations, we collected data from ACTY students, non-ACTY students interested in acute care, and PNITs with approximately six months of acute care experience.

RESULTS

ACTY graduates outperformed non-ACTY graduates on skills and simulations, and had higher odds of coming up to the expectations faculty have of a PNIT, as determined by global ratings. PNITs did better on simulations than ACTY graduates.

DISCUSSION

ACTY graduates show better resemblance to PNITs than non-ACTY graduates, suggesting better preparation for postgraduate acute care challenges.

CONCLUSION

Transitional years, offering multidisciplinary perspectives on a certain theme, can enhance learning and preparedness for entering residency.

A phenomenological study of new doctors' transition to practice, utilising participant-voiced poetry

Transition to practice can be a turbulent time for new doctors. It has been proposed transition is experienced non-linearly in physical, psychological, cultural and social domains. What is less well known, however, is whether transition within these domains can contribute to the experience of moral injury in new doctors. Further, the lived experience of doctors as they transition to practice is underexplored. Given this, we asked; how do newly qualified doctors experience transition from medical school to practice? One-to-one phenomenological interviews with 7 recently qualified UK doctors were undertaken. Findings were analysed using Ajjawi and Higgs' framework of hermeneutic analysis. Following identification of secondary concepts, participant-voiced research poems were crafted by the research team, re-displaying participant words chronologically to convey meaning and deepen analysis. 4 themes were identified: (1) The nature of transition to practice; (2) The influence of community; (3) The influence of personal beliefs and values; and (4) The impact of unrealistic undergraduate experience. Transition to practice was viewed mostly negatively, with interpersonal support difficult to access given the 4-month nature of rotations. Participants describe relying on strong personal beliefs and values, often rooted in an 'ethic of caring' to cope. Yet, in the fraught landscape of the NHS, an ethic of caring can also prove troublesome and predispose to moral injury as trainees work within a fragmented system misaligned with personal values. The disjointed nature of postgraduate training requires review, with focus on individual resilience redirected to tackle systemic health-service issues.

Does simulation training in final year make new graduates feel more prepared for the realities of professional practice?

Introduction

The transition from medical student to doctor has long been a source of concern, with widespread reporting of new graduates’ lack of preparedness for medical practice. Simulation has been suggested as a way to improve preparedness, particularly due to the difficulties in allowing full autonomy for patient care for undergraduate medical students. Few studies look at simulation alone for this purpose, and no studies have compared different simulation formats to assess their impact on preparedness.

Methods

This mixed-method study looked at two different simulation courses in two UK universities. Data were collected in two phases: immediately after the simulation and 3–4 months into the same students’ postgraduate training. Questionnaires provided quantitative data measuring preparedness and interviews provided a more in-depth analysis of experiential learning across final year and how this contributed to preparedness.

Results

There were no significant differences between the two courses for overall preparedness, stress or views on simulation, and no significant differences in opinions longitudinally. Although the study initially set out to look at simulation alone, emergent qualitative findings emphasised experiential learning as key in both clinical and simulated settings. This inter-relationship between simulation and the student assistantship prepared students for practice. Longitudinally, the emphasis on experiential learning in simulation was maintained and participants demonstrated using skills they had practised in simulation in their daily practice as doctors. Nevertheless, there was evidence that although students felt prepared, they were still scared about facing certain scenarios as foundation doctors.

Discussion

The results of this study suggest that simulation may positively affect students’ preparedness for practice as doctors. Simulation will never be a replacement for real clinical experience. However, when used prior to and alongside clinical experience, it may have positive effects on new doctors’ confidence and competence, and, therefore, positively impact patient care.

Switching from a traditional undergraduate programme in (clinical) pharmacology and therapeutics to a problem-based learning programme

PURPOSE

The pharmacology and clinical pharmacology and therapeutics (CPT) education during the undergraduate medical curriculum of NOVA Medical School, Lisbon, Portugal, was changed from a traditional programme (i.e. discipline-based, lectures) to a problem-based learning (PBL) programme (i.e. integrated, case-based discussions) without an increase in teaching hours. The aim of this study was to investigate whether this change improved the prescribing competencies of final-year medical students.

METHODS

Final-year students from both programmes (2015 and 2019) were invited to complete a validated prescribing assessment and questionnaire. The assessment comprised 24 multiple-choice questions in three subdomains (working mechanism, side-effects and interactions/contraindications), and five clinical case scenarios of common diseases. The questionnaire focused on self-reported prescribing confidence, preparedness for future prescribing task and education received.

RESULTS

In total, 36 (22%) final-year medical students from the traditional programme and 54 (23%) from the PBL programme participated. Overall, students in the PBL programme had significantly higher knowledge scores than students in the traditional programme (76% (SD 9) vs 67% (SD 15); p = 0.002). Additionally, students in the PBL programme made significantly fewer inappropriate therapy choices (p = 0.023) and fewer erroneous prescriptions than did students in the traditional programme (p = 0.27). Students in the PBL programme felt more confident in prescribing, felt better prepared for prescribing as junior doctor and completed more drug prescriptions during their medical training.

CONCLUSION

Changing from a traditional programme to an integrated PBL programme in pharmacology and CPT during the undergraduate medical curriculum may improve the prescribing competencies of final-year students.

Twelve tips for facilitating medical students prescribing learning on clinical placement

Prescribing is a complex clinical skill requiring mastery by the end of basic medical training. Prescribing errors are common in newly qualified doctors, aligned with expressed anxiety about prescribing, particularly with high-risk medications. Learning about prescribing needs to start early in medical training, underpinned by regular opportunities for reflective practice. Authentic learning within the clinical work environment is more effective than lecture based learning and allows potential immediate feedback. Educational strategies should support prescribing learning underpinned by appropriate formative and summative assessments. Students should routinely be expected to use resources including an online formulary, sustained through tracking individual progress through use of their own personal formulary or 'p' drugs. Regular prescribing practice with embedded feedback during undergraduate training will help to ensure newly qualified doctors are more confident and competent prescribers.

From the lens of the clinical residents: undergraduate to postgraduate medical education and the transition process

The concept of continuity in medical education reflects the progressive professional and personal development that physicians need in education. The aim of this study is investigating the views of the residents about the adequacy of undergraduate and postgraduate education in the context of preparing them for the next stage and their perceptions about the transition period. This phenomenological study was conducted at Hacettepe University Medical School. The study group consisted of medical and surgical sciences residents in the first year and last year of postgraduate medical education. Four focus group interviews were held with the participation of 21 residents. The participants emphasised that practising with real patients under supervision by taking an active role in healthcare teams was important for their preparation for the next stage in their carrier. However, their educational experiences during undergraduate medical education differed in community-based education, scientific research training, learning in small groups, internship and guidance of clinical educators. The transition period has been expressed with the concepts of identity change, high responsibilities and expectations required by the new identity, adaptation to the healthcare team, institution, and health system, meeting the expectations in an overly busy work environment, and feelings of incompetence. Participants pointed out that curriculum, which was declared and taught, educational environments, assessment approaches, consultancy systems and practices differed between the clinical departments. In line with the principles of competency-based education, practices related to the development and assessment of the competencies with all professional aspects in postgraduate medical education can be strengthened.

Assessing the preparedness of foundation year 1 (FY1) doctors during the transition from medical school to the foundation training programme

BACKGROUND

To assess how ready current FY1 doctors felt when starting their first posting as newly qualified doctors.

METHODS

We created an online survey where 45 FY1 doctors in South Yorkshire rated how confident they were across different domains (Induction and Assistantship, Hospital Systems, and Skills) using a scale ranging from 0 (no confidence performing task) to 5 (highly confident).

RESULTS

The ICE system and observations had a mean rating of 3.645 (95% CI 3.446 to 3.844), and 4.425 (95% CI 4.248 to 4.602) with a standard deviation (SD) of 1.10 and 0.83 respectively. The radiological platform, referral system, telephone system, and hospital notes had a mean score of 3.149 (95% CI 2.876 to 3.422), 2.340 (95% CI 2.096 to 2.584), 3.573 (95% CI 3.407 to 3.739) and 4.061 (95% CI 3.931 to 4.191), with a SD of 1.281, 1.153, 0.961 and 0.752 respectively. Patient needs and diagnostic procedures had a mean score of 3.933 (95% CI 3.749 to 4.117) and 4.250 (95% CI 4.140 to 4.360) with a SD of 1.190 and 0.944 respectively. Patient care, prescribing, and therapeutic procedures gave a mean score of 3.634 (95% CI 3.432 to 3.836), 4.130 (95% CI 3.959 to 4.301), 3.386 (95% CI 3.228 to 3.544) with a SD of 1.133, 0.958 and 1.256 respectively. No statistically significant difference in the overall mean score was found between respondents who attended medical schools in Yorkshire, and those who had not.

CONCLUSION

Overall, confidence differs across different domains and categories. A larger sample size across a wider geographical area would allow us to compare and contrast results across the different regions in the UK.

Preparedness of medical students and junior doctors for their role as clinical leaders: A systematic review

Introduction: Clinical leadership skills are essential across all levels of a healthcare organization and must be employed by those most appropriate to the situation, regardless of position or profession. However, most medical students and junior doctors remain unaware of how leadership can be assimilated into their everyday clinical practice.Aim: To investigate the perceived preparedness of medical students and junior doctors for their role as clinical leaders.Methods: A systematic search was performed of the MEDLINE, ERIC and PubMed databases. Papers pertaining to medical students and junior doctors that included primary data on preparedness for clinical leadership or behaviors associated with being a clinical leader were included.Results: Sixteen papers were included and analyzed after screening 254. No studies specifically assessed the transition to clinical leader. Evidence suggests that new graduates perceive leadership as individualistic and hierarchical, and that they are only partially prepared to fill this role. Preparedness for clinical leadership was associated with increasing responsibility, experience and time-served.Conclusions: New graduates are unlikely to question senior colleagues as they lack leadership-specific communication skills. Further research is required into how to actively promote leadership in medical students and ease the transition to leadership roles within clinical teams.

'Waiting in the wings'; Lived experience at the threshold of clinical practice

CONTEXT

The transition to clinical practice is challenging. Lack of preparedness and issues with support, responsibility and complex workplace interactions contribute to the difficulties encountered. The first year of clinical practice is associated with negative consequences for new doctors' health and well-being. The contemporaneous lived experience of new graduates on the threshold of clinical practice has not been described. Deeper understanding of this phase may inform interventions to ease the transition from student to doctor.

METHODS

We used interpretative phenomenological analysis (IPA) to explore the individual experience of making the transition from medical student to doctor, focusing on the period prior to commencing clinical practice. Fourteen recent graduates were purposively recruited, and semi-structured interviews were conducted with each, with respect to how they anticipated the transition.

RESULTS

We draw on the metaphor of the actor 'waiting in the wings' to describe participants' lived experience on the threshold of practice. The experience of the actor, about to step into the spotlight, was mirrored in participants' perceptions of an abrupt transformation to come, mixed feelings about what lay ahead, and the various strategies that they had planned to help them to perform their new role convincingly.

DISCUSSION

Participants in this study braced themselves for a trial by ordeal as they contemplated commencing clinical practice. The hidden curriculum shaped their understanding of what was expected of them as new doctors, and inspired dysfunctional strategies to meet expectations. Solutions to make the experience a more positive one lie in the approximation of the roles of senior medical student and newly qualified doctor, in explicitly addressing the hidden curriculum and generating cultural change. An emphasis on experience-based learning through contribution to patient care, guided reflection on the hidden curriculum and shifting cultural expectations through faculty development and strong local leadership can contribute to these objectives.

Ready to run the wards? - A descriptive follow-up study assessing future doctors' clinical skills

BACKGROUND

Recent studies have shown that clinical tasks only represent a small percentage in the scope of final-year medical students' activities and often lack sufficient supervision. It appears that final-year medical students are frequently deployed to perform "routine tasks" and show deficits in the performance of more complex activities. This study aimed to evaluate final-year students' clinical performance in multiple impromptu clinical scenarios using video-based assessment.

METHODS

We assessed final-year medical students' clinical performance in a prospective, descriptive, clinical follow-up study with 24 final-year medical students during their Internal Medicine rotation. Participating students were videotaped while practicing history taking, physical examination, IV cannulation, and case presentation at the beginning and end of their rotation. Clinical performance was rated by two independent, blinded video assessors using binary checklists, activity specific rating scales and a five-point global rating scale for clinical competence.

RESULTS

Students' performance, assessed by the global rating scale for clinical competence, improved significantly during their rotation. However, their task performance was not rated as sufficient for independent practice in most cases. Analysis of average scores revealed that overall performance levels differed significantly, whereby average performance was better for less complex and more frequently performed activities.

CONCLUSIONS

We were able to show that students' performance levels differ significantly depending on the frequency and complexity of activities. Hence, to ensure adequate job preparedness for clinical practice, students need sufficiently supervised and comprehensive on-ward medical training.

How well are Swiss French physicians prepared for future practice in primary care?

BACKGROUND

Moving from postgraduate training into independent practice represents a major transition in physicians' professional life. Little is known about how Swiss primary care graduates experience such a transition. The aim of this study was to explore the extent to which primary care physicians who recently set up private practice felt prepared to work as independent practitioners.

METHODS

We conducted 7 focus groups among recently established (≤ 5 years) primary care physicians in Switzerland. Questions focused on positive and negative aspects of setting up a practice, and degree of preparedness. Transcripts were analysed according to organisational socialisation and work role transition frameworks.

RESULTS

Participants felt relatively well prepared for most medical tasks except for some rheumatologic, minor traumatology, ENR, skin and psychiatric aspects. They felt unprepared for non clinical tasks such as office, insurance and medico-legal management issues and did not anticipate that the professional networking outside the hospital would be so important to their daily work. They faced dilemmas opposing professional values to the reality of practice which forced them to clarify their professional roles and expectations. Adjustment strategies were mainly informal.

CONCLUSION

Although the postgraduate primary care curriculum is longer in Switzerland than in most European countries, it remains insufficiently connected with the reality of transitioning into independent practice, especially regarding role development and management tasks. A greater proportion of postgraduate training, with special emphasis on these issues, should take place directly in primary care.

Nurturing professional identity through a community based education program: medical students experience

Objectives

Community-based education (CBE) has an impact on the types of medical students produced at the end of medical training. However, its impact on professional identity development (PID) has not been clearly understood. This study thus explores the effect of the CBE program on PID.

Methods

A qualitative phenomenological study was conducted on a group of Universiti Sains Malaysia medical students who had finished the Community and Family Case Study (CFCS) program. Data were gathered through focused group discussions and student reflective journals. Participants were sampled using the maximal variation technique of purposive sampling. Three steps of thematic analysis using the Atlasti software were employed to identify categories, subthemes, and themes.

Results

Personal, role, social, and research identities were generated that contribute to the PID of medical students through the CFCS program. The results indicate that the CFCS program nurtured personal identity through the development of professional skills, soft skills, and personal values. Pertaining to role identity, this is related to patient care in terms of primary care and interprofessional awareness. Pertaining to social identity, the obvious feature was community awareness related to culture, society, and politics. A positive outcome of the CFCS program was found to be its fostering of research skills, which is related to the use of epidemiology and research methods.

Conclusion

The findings indicate that the CFCS program promotes PID among medical students. The current data highlight and provide insights into the importance of integrating CBE into medical curricula to prepare future doctors for their entry into the profession.

Preparation courses for medical clerkships and the final clinical internship in medical education - The Magdeburg Curriculum for Healthcare Competence

BACKGROUND/GOALS

Supporting medical students entering their internships - the clinical clerkship and the internship "final clinical year" (Praktisches Jahr, PJ) - the seminars "Ready for Clerkship" and "Ready for PJ" were held for the first time in 2014 and continued successfully in 2015. These seminars are part of the "Magdeburg Curriculum for Healthcare Competence" (Magdeburger Curriculum zur Versorgungskompetenz, MCV). The concept comprises three main issues: "Understanding interdisciplinary clinical procedures", "Interprofessional collaboration", and "Individual cases and their reference to the system." The aim of the seminar series is to prepare students as medical trainees for their role in the practice-oriented clinical clerkship and PJ, respectively.

METHODS

Quality assurance evaluations and didactic research are integral parts of the seminars. In preparation for the "Ready for PJ" seminar a needs assessment was conducted. The seminars were rated by the participants using an anonymized questionnaire consisting of a 5-choice Likert scale (ranging from 1=fully agree to 5=fully disagree) and spaces for comments that was generated by the evaluation software Evasys.

RESULTS

The results are presented for the preparatory seminars "Ready for Clerkship" and "Fit für PJ" held in 2014 and 2015. Overall, the students regarded the facultative courses as very good preparation for the clerkship as well as for the PJ. The three-dimensional main curricular concept of the MCV was recognized in the evaluation as a valuable educational approach. Interprofessional collaboration, taught by instructors focussing in teamwork between disciplines, was scored positively and highly valued.

CONCLUSIONS

The "Magdeburg Curriculum for Healthcare Competence" (MCV) integrates clerkship and PJ in a framing educational concept and allows students a better appreciation of their role in patient care and the tasks that they will face. The MCV concept can be utilized in other practice-oriented phases (nursing internship, bed-side teaching, block internships).

Perceptions of the preparedness of medical graduates for internship responsibilities in district hospitals in Kenya: a qualitative study

BACKGROUND

Aga Khan University is developing its undergraduate medical education curriculum for East Africa. In Kenya, a 1 year internship is mandatory for medical graduates' registration as practitioners. The majority of approved internship training sites are at district hospitals. The purposes of this study were to determine: (1) whether recent Kenyan medical graduates are prepared for their roles as interns in district hospitals upon graduation from medical school; (2) what working and training conditions and social support interns are likely to face in district hospital; and (3) what aspects of the undergraduate curriculum need to be addressed to overcome perceived deficiencies in interns' competencies.

METHODS

Focus group discussions and semi-structured interviews were conducted with current interns and clinical supervisors in seven district hospitals in Kenya. Perceptions of both interns and supervisors regarding interns' responsibilities and skills, working conditions at district hospitals, and improvements required in medical education were obtained.

RESULTS

Findings included agreement across informants on deficiencies in interns' practical skills and experience of managing clinical challenges. Supervisors were generally critical regarding interns' competencies, whereas interns were more specific about their weaknesses. Supervisor expectations were higher in relation to surgical procedures than those of interns. There was agreement on the limited learning, clinical facilities and social support available at district hospitals including, according to interns, inadequate supervision. Supervisors felt they provided adequate supervision and that interns lacked the ability to initiate communication with them. Both groups indicated transition challenges from medical school to medical practice attributable to inadequate practical experience. They indicated the need for more direct patient care responsibilities and clinical experience at a district hospital during undergraduate training.

CONCLUSION

Perception of medical graduates' unpreparedness seemed to stem from a failure to implement the apprenticeship model of learning in medical school and lack of prior exposure to district hospitals. These findings will inform curriculum development to meet stakeholder requirements, improve the quality of graduates, and increase satisfaction with transition to practice.

Perceptions of the preparedness of medical graduates for internship responsibilities in district hospitals in Kenya: a qualitative study

BACKGROUND

Aga Khan University is developing its undergraduate medical education curriculum for East Africa. In Kenya, a 1 year internship is mandatory for medical graduates' registration as practitioners. The majority of approved internship training sites are at district hospitals. The purposes of this study were to determine: (1) whether recent Kenyan medical graduates are prepared for their roles as interns in district hospitals upon graduation from medical school; (2) what working and training conditions and social support interns are likely to face in district hospital; and (3) what aspects of the undergraduate curriculum need to be addressed to overcome perceived deficiencies in interns' competencies.

METHODS

Focus group discussions and semi-structured interviews were conducted with current interns and clinical supervisors in seven district hospitals in Kenya. Perceptions of both interns and supervisors regarding interns' responsibilities and skills, working conditions at district hospitals, and improvements required in medical education were obtained.

RESULTS

Findings included agreement across informants on deficiencies in interns' practical skills and experience of managing clinical challenges. Supervisors were generally critical regarding interns' competencies, whereas interns were more specific about their weaknesses. Supervisor expectations were higher in relation to surgical procedures than those of interns. There was agreement on the limited learning, clinical facilities and social support available at district hospitals including, according to interns, inadequate supervision. Supervisors felt they provided adequate supervision and that interns lacked the ability to initiate communication with them. Both groups indicated transition challenges from medical school to medical practice attributable to inadequate practical experience. They indicated the need for more direct patient care responsibilities and clinical experience at a district hospital during undergraduate training.

CONCLUSION

Perception of medical graduates' unpreparedness seemed to stem from a failure to implement the apprenticeship model of learning in medical school and lack of prior exposure to district hospitals. These findings will inform curriculum development to meet stakeholder requirements, improve the quality of graduates, and increase satisfaction with transition to practice.

Video-based on-ward supervision for final year medical students

BACKGROUND

Constructive feedback is an essential element of the educational process, helping trainees reach their maximum potential and increasing their skill level. Video-based feedback has been described as highly effective in various educational contexts. The present study aimed to evaluate the feasibility and acceptability of video-based, on-ward supervision for final year students in a clinical context with real patients.

METHODS

Nine final year medical students (three male, six female; aged 25.1 ± 0.7 years) and eight patients (five male, three female; aged 59.3 ± 16.8 years) participated in the pilot study. Final year students performed routine medical procedures at bedside on internal medicine wards at the University of Heidelberg Medical Hospital. Students were filmed and were under supervision. After performing the procedures, an oral feedback loop was established including student, patient and supervisor feedback on communicative and procedural aspects of skills performed. Finally, students watched their video, focusing on specific teachable moments mentioned by the supervisor. Written evaluations and semi-structured interviews were conducted that focused on the benefits of video-based, on-ward supervision. Interviews were analysed qualitatively, using open coding to establish recurring themes and overarching categories to describe patients' and students' impressions. Descriptive, quantitative analysis was used for questionnaire data.

RESULTS

Supervised, self-chosen skills included history taking (n = 6), physical examination (n = 1), IV cannulation (n = 1), and ECG recording (n = 1). The video-based, on-ward supervision was well accepted by patients and students. Supervisor feedback was rated as highly beneficial, with the video material providing an additional opportunity to focus on crucial aspects and to further validate the supervisor's feedback. Students felt the video material would be less beneficial without the supervisor's feedback. The setting was rated as realistic, with filming not influencing behaviour.

CONCLUSION

Video-based, on-ward supervision may be a powerful tool for improving clinical medical education. However, it should be regarded as an additional tool in combination with supervisors' oral feedback. Acceptance was high in both students and patients. Further research should address possibilities of efficiently combining and routinely establishing these forms of feedback in medical education.

Self-reported confidence in prescribing skills correlates poorly with assessed competence in fourth-year medical students

The objective of this study was to investigate the relationship between students' self-reported confidence and their objectively assessed competence in prescribing. We assessed the competence in several prescribing skills of 403 fourth-year medical students at the VU University Medical Center, the Netherlands, in a formative simulated examination on a 10-point scale (1 = very low; 10 = very high). Afterwards, the students were asked to rate their confidence in performing each of the prescribing skills on a 5-point Likert scale (1 = very unsure; 5 = very confident). Their assessments were then compared with their self-confidence ratings. Students' overall prescribing performance was adequate (7.0 ± 0.8), but they lacked confidence in 2 essential prescribing skills. Overall, there was a weak positive correlation (r = 0.2, P < .01, 95%CI 0.1-0.3) between reported confidence and actual competence. Therefore, this study suggests that self-reported confidence is not an accurate measure of prescribing competence, and that students lack insight into their own strengths and weaknesses in prescribing. Future studies should focus on developing validated and reliable instruments so that students can assess their prescribing skills.

Junior doctor-led 'near-peer' prescribing education for medical students

AIMS

Prescribing errors are common and inadequate preparation of prescribers appears to contribute. A junior doctor-led prescribing tutorial programme has been developed for Edinburgh final year medical students to increase exposure to common prescribing tasks. The aim of this study was to assess the impact of these tutorials on students and tutors.

METHODS

One hundred and ninety-six tutorials were delivered to 183 students during 2010-2011. Each student completed a questionnaire after tutorial attendance which explored their previous prescribing experiences and the perceived benefits of tutorial attendance. Tutors completed a questionnaire which evaluated their teaching experiences and the impact on their prescribing practice. Student tutorial attendance was compared with end-of-year examination performance using linear regression analysis.

RESULTS

The students reported increased confidence in their prescribing knowledge and skills after attending tutorials. Students who attended more tutorials also tended to perform better in end-of-year examinations (Drug prescribing: r = 0.16, P = 0.015; Fluid prescribing: r = 0.18, P = 0.007). Tutors considered that participation enhanced their own prescribing knowledge and skills. Although they were occasionally unable to address student uncertainties, 80% of tutors reported frequently correcting misconceptions and deficits in student knowledge. Ninety-five percent of students expressed a preference for prescribing training delivered by junior doctors over more senior doctors.

CONCLUSIONS

A 'near-peer' junior doctor-led approach to delivering prescribing training to medical students was highly valued by both students and tutors. Although junior doctors have relatively less clinical experience of prescribing, we believe that this can be addressed by training and academic supervision and is outweighed by the benefits of these tutorials.

Workplace learning: an analysis of students' expectations of learning on the ward in the Department of Internal Medicine

Background: Learning on the ward as a practice-oriented preparation for the future workplace plays a crucial role in the medical education of future physicians. However, students’ ward internship is partially problematic due to condensed workflows on the ward and the high workload of supervising physicians. For the first time in a German-speaking setting, students’ expectations and concerns about their internship on the ward are examined in a qualitative analysis regarding their internal medicine rotation within clinical medical education.

Methods: Of a total of 168 medical students in their 6th semester at the Medical Faculty of Heidelberg, 28 students (m=8, f=20, Ø 23.6 years) took part in focus group interviews 3 to 5 days prior to their internship on the internal medicine ward within their clinical internal medicine rotation. Students were divided into four different focus groups. The protocols were transcribed and a content analysis was conducted based on grounded theory.

Results: We gathered a total of 489 relevant individual statements. The students hope for a successful integration within the ward team, reliable and supportive supervisors and supervision in small groups. They expect to face the most common diseases, to train the most important medical skills, to assume full responsibility for their own patients and to acquire their own medical identity. The students fear an insufficient time frame to achieve their aims. They are also concerned they will have too little contact with patients and inadequate supervision.

Conclusion: For the development and standardization of effective student internships, the greatest relevance should be attributed to guidance and supervision by professionally trained and well-prepared medical teachers, entailing a significant increase in staff and costs. A structural framework is required in order to transfer the responsibility for the treatment of patients to the students at an early stage in medical education and in a longitudinal manner. The data suggest that the development and establishment of guidelines for medical teachers associated with clearly defined learning objectives for the students’ internships are urgently needed. Based on our findings, we provide first recommendations and suggest possible solutions.

Assessment of quality of prescription by dental students

Objective

The main objective of this study was to evaluate changes in prescribing pattern of Dentistry students throughout academic course.

Methods

A case of non-complicated dental extraction was presented to all students that had completed their pharmacology coursework (from 4th semester to the last semester). The students were grouped according to year of study and were asked to prescribe paracetamol for pain control. A maximal score of 5 points was calculated from three subscores for identification of professional and patient (1.0 point), drug concentration, dosage, and quantity (1.5 points); and drug information, instructions, and warnings (2.5 points). The data were expressed as medians [95% confidence intervals (CIs)] and were compared using the Kruskal-Wallis test followed by Dunn's post hoc test. A p<0.05 value was considered statistically significant. A total of 92 students participated the study (2^nd year, N=12; 3^rd year, N=32; 4^th year, N=28; 5^th year, N=20).

Results

The quality of prescription showed improvement between 2^nd-year students [2.0 (1.5-2.5)] and 4^th-year students [3.2 (2.9-3.5), p<0.05]; 4^th- and 5^th-year students [3.6 (3.5-3.8)] performed similarly. Lack of information about pharmacological treatment, side effects, and administration route were the major deficiencies observed.

Conclusion

Although Dentistry students present a general improvement in their prescribing performance, deficiencies remain even in advanced students. The data suggest that the teaching of good prescription practices should extend throughout the later phases of preprofessional dental education.

Blind prescribing: a study of junior doctors' prescribing preparedness in an Australian emergency department

OBJECTIVES

The present study examined junior residents' and registrars' preparedness to prescribe in an Australian ED. It measured the medication knowledge of participants and identified antecedent factors relevant to prescribing practice.

METHODS

This is a prospective, exploratory study of the prescribing practices of 40 junior doctors. Data collection consisted of a participant questionnaire with three parts. Part A comprised demographic information; Part B comprised questions regarding prescribing practices; and Part C was an objective assessment of the doctor's knowledge of the most recently and most commonly prescribed medications.

RESULTS

One hundred percent (n = 40) of doctors in the study had inadequate knowledge about at least one medication when an accuracy threshold of <80% correct was used. Seventy percent (n = 28) of the participants had inadequate knowledge of at least one medication when the lower accuracy threshold of <50% correct was used. Comparisons between medication knowledge score and Likert confidence scales showed that even though a doctor reported being completely sure about an individual medication, they most commonly only answered between four and six of the eight questions correctly for that medication. Their use of reference materials was also lacking in relation to their knowledge and level of confidence. The reported reasons for this included instructions by senior staff and time constraints.

CONCLUSIONS

The majority of participants in the study had inadequate knowledge on medications they had most recently prescribed and medications most commonly prescribed in the ED. Junior doctors' perceptions of their medication knowledge were inflated in relation to their actual knowledge.

Perceptions of UK medical graduates' preparedness for practice: a multi-centre qualitative study reflecting the importance of learning on the job

BACKGROUND

There is evidence that graduates of different medical schools vary in their preparedness for their first post. In 2003 Goldacre et al. reported that over 40% of UK medical graduates did not feel prepared and found large differences between graduates of different schools. A follow-up survey showed that levels of preparedness had increased yet there was still wide variation. This study aimed to examine whether medical graduates from three diverse UK medical schools were prepared for practice.

METHODS

This was a qualitative study using a constructivist grounded theory approach. Prospective and cross-sectional data were collected from the three medical schools.A sample of 60 medical graduates (20 from each school) was targeted. They were interviewed three times: at the end of medical school (n = 65) and after four (n = 55) and 12 months (n = 46) as a Year 1 Foundation Programme doctor. Triangulated data were collected from clinicians via interviews across the three sites (n = 92). In addition three focus groups were conducted with senior clinicians who assess learning portfolios. The focus was on identifying areas of preparedness for practice and any areas of lack of preparedness.

RESULTS

Although selected for being diverse, we did not find substantial differences between the schools. The same themes were identified at each site. Junior doctors felt prepared in terms of communication skills, clinical and practical skills and team working. They felt less prepared for areas of practice that are based on experiential learning in clinical practice: ward work, being on call, management of acute clinical situations, prescribing, clinical prioritisation and time management and dealing with paperwork.

CONCLUSIONS

Our data highlighted the importance of students learning on the job, having a role in the team in supervised practice to enable them to learn about the duties and responsibilities of a new doctor in advance of starting work.

A systematic review of educational interventions to change behaviour of prescribers in hospital settings, with a particular emphasis on new prescribers

AIMS

Prescribing is a complex task and a high risk area of clinical practice. Poor prescribing occurs across staff grades and settings but new prescribers are attributed much of the blame. New prescribers may not be confident or even competent to prescribe and probably have different support and development needs than their more experienced colleagues. Unfortunately, little is known about what interventions are effective in this group. Previous systematic reviews have not distinguished between different grades of staff, have been narrow in scope and are now out of date. Therefore, to inform the design of educational interventions to change prescribing behaviour, particularly that of new prescibers, we conducted a systematic review of existing hospital-based interventions.

METHODS

Embase, Medline, SIGLE, Cinahl and PsychINFO were searched for relevant studies published 1994-2010. Studies describing interventions to change the behaviour of prescribers in hospital settings were included, with an emphasis on new prescibers. The bibliographies of included papers were also searched for relevant studies. Interventions and effectiveness were classified using existing frameworks and the quality of studies was assessed using a validated instrument.

RESULTS

Sixty-four studies were included in the review. Only 13% of interventions specifically targeted new prescribers. Most interventions (72%) were deemed effective in changing behaviour but no particular type stood out as most effective.

CONCLUSION

Very few studies have tailored educational interventions to meet needs of new prescribers, or distinguished between new and experienced prescribers. Educational development and research will be required to improve this important aspect of early clinical practice.

Designing a purposeful student assistantship

BACKGROUND

The student assistantship, during which medical students act as assistants to junior doctors, is currently being integrated into all UK medical school curricula. However, there is a dearth of evidence to guide design and implementation, particularly in relation to the priorities for student learning. This study aimed to explore the specific learning opportunities within an assistantship that are perceived as important by foundation year-1 doctors (FY1s) and their educational supervisors.

METHODS

A questionnaire study of University of Edinburgh graduates, and their educational supervisors, was undertaken in January 2011. The survey investigated the perceived importance of 16 predefined learning opportunities, and asked respondents to indicate the learning opportunity that they regarded as most important. Free-text responses relating to other beneficial components were sought and thematically analysed.

RESULTS

All 16 learning opportunities were regarded as useful by over 80 per cent of FY1s, and over 50 per cent of educational supervisors. The opportunities considered most important by both FY1s and educational supervisors were prescribing drugs and fluids, providing emergency care and prioritisation of tasks. Free-text responses suggested that experience of out-of-hours working, administrative tasks and the theatre environment were also important.

DISCUSSION

By asking FY1s and educational supervisors to consider the most useful learning opportunity, it has been possible to use the respective rankings to guide the design and implementation of the assistantship. Our future challenge is to develop ways of allowing students to gain experience in the areas considered most important, whilst ensuring the safety of patients.

Teaching the Rational Use of Medicines to medical students: a qualitative research

BACKGROUND

Prescribing is a complex and challenging task that must be part of a logical deductive process based on accurate and objective information and not an automated action, without critical thinking or a response to commercial pressure. The objectives of this study were 1) develop and implement a discipline based on the WHO's Guide to Good Prescribing; 2) evaluate the course acceptance by students; 3) assess the impact that the Rational Use of Medicines (RUM) knowledge had on the students habits of prescribing medication in the University Hospital.

METHODS

In 2003, the RUM principal, based in the WHO's Guide to Good Prescribing, was included in the official curriculum of the Botucatu School of Medicine, Brazil, to be taught over a total of 24 hours to students in the 4th year. We analyzed the students' feedback forms about content and teaching methodology filled out immediately after the end of the discipline from 2003 to 2010. In 2010, the use of RUM by past students in their medical practice was assessed through a qualitative approach by a questionnaire with closed-ended rank scaling questions distributed at random and a single semistructured interview for content analysis.

RESULTS

The discipline teaches future prescribers to use a logical deductive process, based on accurate and objective information, to adopt strict criteria (efficacy, safety, convenience and cost) on selecting drugs and to write a complete prescription. At the end of it, most students considered the discipline very good due to the opportunity to reflect on different actions involved in the prescribing process and liked the teaching methodology. However, former students report that although they are aware of the RUM concepts they cannot regularly use this knowledge in their daily practice because they are not stimulated or even allowed to do so by neither older residents nor senior medical staff.

CONCLUSIONS

This discipline is useful to teach RUM to medical students who become aware of the importance of this subject, but the assimilation of the RUM principles in the institution seems to be a long-term process which requires the involvement of a greater number of the academic members.

Pediatric pain management education in medical students: impact of a web-based module

OBJECTIVE

Reports from the Institute of Medicine and American Medical Association's Pain and Palliative Medicine Specialty Section Council emphasize the need for pain management education in medical schools, yet training in pediatric pain management (PPM) is limited. In this pilot program, we evaluated the effectiveness of a web-based PPM module on knowledge, confidence, attitudes, and self-reported skills in medical students.

METHODS

Third- and fourth-year medical students (n = 291) completed the module and a knowledge test. Of these students, 53 completed a pre- and postsurvey of confidence, attitudes, and self-reported skills and module evaluation.

RESULTS

For the 291 students, knowledge scores increased significantly by 21.8 points (95% confidence interval [CI] = 19.7-23.8; p<0.001). The majority of scores on the survey items significantly increased postmodule, including: increase in confidence in assessing pain in pediatric patients (6% to 25%; p = 0.004), increase in responses of "strongly disagree" or "disagree" to the belief that opioids will delay diagnosis (62% to 85%; p = 0.005), and increase in responses of "frequently" or "very frequently" to "how often do you use behavioral instruments to assess pain severity?" (35% to 57%; p = 0.008). The majority reported they intend to make changes in behavior or practice (71%), and would recommend the module to fellow students (88%).

CONCLUSION

This pilot program supports the effectiveness of a web-based module in improving knowledge, confidence, attitudes, and self-reported skills in PPM. Evaluation responses indicate high-quality content. Further evaluation for sustained impact is warranted.

Does doctors' workload impact supervision and ward activities of final-year students? A prospective study

BACKGROUND

Hospital doctors face constantly increasing workloads. Besides caring for patients, their duties also comprise the education of future colleagues. The aim of this study was to objectively investigate whether the workload arising from increased patient care interferes with student supervision and is associated with more non-medical activities of final-year medical students.

METHODS

A total of 54 final-year students were asked to keep a diary of their daily activities over a three-week period at the beginning of their internship in Internal Medicine. Students categorized their activities--both medical and non-medical--according to whether they had: (1) only watched, (2) assisted the ward resident, (3) performed the activity themselves under supervision of the ward resident, or (4) performed the activity without supervision. The activities reported on a particular day were matched with a ward specific workload-index derived from the hospital information system, including the number of patients treated on the corresponding ward on that day, a correction factor according to the patient comorbidity complexity level (PCCL), and the number of admissions and discharges. Both students and ward residents were blinded to the study question.

RESULTS

A total of 32 diaries (59 %, 442 recorded working days) were handed back. Overall, the students reported 1.2 ± 1.3 supervised, 1.8 ± 1.6 medical and 3.6 ± 1.7 non-medical activities per day. The more supervised activities were reported, the more the number of reported medical activities increased (p < .0001). No relationship between the ward specific workload and number of medical activities could be shown.

CONCLUSIONS

There was a significant association between ward doctors' supervision of students and the number of medical activities performed by medical students. The workload had no significant effect on supervision or the number of medical or non-medical activities of final-year students.

Junior doctors prescribing: enhancing their learning in practice

AIM

This aim of this paper was to explore new doctors' preparedness for prescribing.

METHODS

This was a multiple methods study including face-to-face and telephone interviews, questionnaires and secondary data from a safe prescribing assessment (n= 284). Three medical schools with differing curricula and cohorts were included: Newcastle (systems-based, integrated curriculum); Warwick (graduate entry) and Glasgow [problem-based learning (PBL)], with graduates entering F1 in their local deanery. The primary sample consisted of final year medical students, stratified by academic quartile (n= 65) from each of the three UK medical schools. In addition an anonymous cohort questionnaire was distributed at each site (n= 480), triangulating interviews were conducted with 92 clinicians and questionnaire data were collected from 80 clinicians who had worked with F1s.

RESULTS

Data from the primary sample and cohort data highlighted that graduates entering F1 felt under-prepared for prescribing. However there was improvement over the F1 year through practical experience and support. Triangulating data reinforced the primary sample findings. Participants reported that learning in an applied setting would be helpful and increase confidence in prescribing. No clear differences were found in preparedness to prescribe between graduates of the three medical schools.

CONCLUSION

The results form part of a larger study 'Are medical graduates fully prepared for practice?'. Prescribing was found to be the weakest area of practice in all sources of data. There is a need for more applied learning to develop skill-based, applied aspects of prescribing which would help to improve preparedness for prescribing.

Participation and progression: new medical graduates entering professional practice

The first year of practice after medical school is considered to be an essential part of becoming a medical practitioner in Australia. Previous qualitative investigations have investigated a number of significant aspects of this early stage of professional development. This qualitative study explores experiences and developing professional identities during internship. Thirty interns and six intern supervisors were interviewed from three different Australian states. Grounded theory techniques were used to develop three key themes: internship-as-participation, internship-as-progression, and conflicts, parallels, disturbances and outliers. Key findings were: the important balance between support from colleagues and development through taking independent responsibility; and the strength of the view of internship as part of a 'natural progression', an inevitable evolution through the stages of medical training.

Preparedness is not enough: understanding transitions as critically intensive learning periods

OBJECTIVES

Doctors make many transitions whilst they are training and throughout their ensuing careers. Despite studies showing that transitions in other high-risk professions such as aviation have been linked to increased risk in the form of adverse outcomes, the effects of changes on doctors' performance and consequent implications for patient safety have been under-researched. The purpose of this project was to investigate the effects of transitions upon medical performance.

METHODS

The project sought to focus on the inter-relationships between doctors and the complex work settings into which they transition. To this end, a 'collective' case study of doctors was designed. Key transitions for foundation year and specialist trainee doctors were studied. Four levels of the case were examined, pertaining to: the regulatory and policy context; employer requirements; the clinical teams in which doctors worked, and the doctors themselves. Data collection methods included interviews, observations and desk-based research.

RESULTS

A number of problems with doctors' transitions that can all adversely affect performance were identified. (i) Transitions are regulated but not systematically monitored. (ii) Actual practice (as observed and reported) was determined much more by situational and contextual factors than by the formal (regulatory and management) frameworks. (iii) Trainees' and health professionals' accounts of their actual experiences of work showed how performance is dependent on the local learning environment. (iv) The increased regulation of clinical activity through protocols and care pathways helps to improve trainees' performance, whereas the less regulated aspects of work, such as rotas, induction and the making of multiple transitions within rotations, can impede performance during a period of transition.

CONCLUSIONS

Transitions may be reframed as critically intensive learning periods (CILPs) in which doctors engage with the particularities of the setting and establish working relationships with other doctors and other professionals. Institutions and wards have their own learning cultures which may or may not recognise that transitions are CILPS. The extent to which these cultures take account of transitions as CILPs will contribute to the performance of new doctors. Thus, these findings have implications for practice and for policy, regulation and research.

Why are newly qualified doctors unprepared to care for patients at the end of life?

CONTEXT

Death and dying occur in almost all areas of medicine; it is essential to equip doctors with the knowledge, skills and attitudes they need to care for patients at the end of life. Little is known about what doctors learn about end-of-life care while at medical school and how they learn to care for dying patients in their first year as doctors.

METHODS

We carried out a qualitative study using face-to-face interviews with a purposive sample of 21 newly qualified doctors who trained in different medical schools.

RESULTS

Data were analysed using a constant comparative approach. Two main groups of themes emerged. The first pertained to medical school experiences of end-of-life care, including: lack of exposure; a culture of 'clerking and signs'; being kept and keeping away from dying patients; lack of examinations; variable experiences, and theoretical awareness. The second group of themes pertained to the experiences of recently qualified doctors and included: realising that patients really do die; learning by doing; the role of seniors; death and dying within the hospital culture; the role of nursing staff, and the role of the palliative care team.

CONCLUSIONS

Undergraduate medical education is currently failing to prepare junior doctors for their role in caring for dying patients by omitting to provide meaningful contact with these patients during medical school. This lack of exposure prevents trainee doctors from realising their own learning needs, which only become evident when they step onto the wards as doctors and are expected to care for these patients. Newly qualified doctors perceive that they receive little formal teaching about palliative or end-of-life care in their new role and the culture within the hospital setting does not encourage learning about this subject. They also report that they learn from 'trial and error' while 'doing the job', but that their skills and knowledge are limited and they therefore seek advice from those outside their usual medical team, mainly from nursing staff and members of palliative care teams.

Development of learning outcomes for an undergraduate prescribing curriculum (British Pharmacological Society prescribing initiative)

AIMS

The question of whether new medical graduates are adequately prepared for the challenge of prescribing has been raised. Although broad outcomes for prescribing competency have been agreed, clarity is needed on the detailed outcomes expected of new graduates. This study aimed to create a consensus on the required competencies for new graduates in the area of prescribing.

METHODS

We used a modified Delphi approach based on the findings of a systematic review of educational interventions for improved prescribing. Panellists were asked to rank the importance of a list of 53 possible learning outcomes and to add any additional outcomes felt to be missing.

RESULTS

Of the 48 experts who were invited to participate, 28 agreed (58%). Forty-five learning outcomes were included from the original list of 53. A further nine outcomes were suggested by panellists, of which five were included. The wording of three outcomes was changed in line with suggestions from the panellists. Many of the agreed outcomes relate to improving patient safety through medication review, checking appropriateness of the drug for the patient, recognizing the prescriber's limitations and seeking advice when needed. Enhanced communication with the patient and healthcare team, better documentation in the notes and discharge letters were key areas featured in this Delphi exercise.

DISCUSSION

This study has identified 50 learning outcomes for teaching prescribing. These build on the existing British Pharmacological Society document by focusing specifically on prescribing, with greater emphasis on avoiding medication errors and better communication.

Impact of a focussed teaching programme on practical prescribing skills among final year medical students

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Medication errors, and particularly prescribing errors, are common in UK hospitals. Junior doctors make the majority of prescribing errors. Deficiencies in prescribing education and training have been closely linked to the high frequency of medication errors.

WHAT THIS STUDY ADDS

Focussed prescribing teaching can lead to an improvement in prescribing ability. Prescribing confidence can be significantly improved through education. Education is insufficient alone in eradicating prescribing errors.

AIM

To assess the impact of prescribing teaching on final year medical students.

METHODS

Students randomly allocated to two hospitals completed a prescribing assessment. Prescribing teaching was delivered to the intervention group while no additional teaching was provided for the control group. All students then completed a second prescribing assessment.

RESULTS

Teaching improved the assessment score: mean assessment 2 vs. 1, 70% vs. 62%, P= 0.007; allergy documentation: 98% vs. 74%, P= 0.0001; and confidence. However, 30% of prescriptions continued to include prescribing errors.

CONCLUSION

Medical students make significant errors in prescribing. Teaching improves ability and confidence but is insufficient alone in eradicating errors.

Opportunity or threat: the ambiguity of the consequences of transitions in medical education

OBJECTIVES

The alleged medical education continuum is interrupted by a number of major transitions. After starting medical school, the first transition students encounter is that from non-clinical to clinical training. The second transition is that of graduated student to junior doctor or specialist trainee, and the third concerns the specialist trainee's transition to medical specialist. As a first step towards a better understanding of the effects of transitions, this paper provides a critical overview of how these transitions have been conceptualised in the medical education domain. The findings are complemented with perspectives from the fields of transitional psychology and organisational socialisation. The transition into medical school is not reviewed.

METHODS

Using the term 'transition', six leading medical education journals were searched for relevant articles. A snowballing technique on the reference lists of the 44 relevant articles yielded 29 additional publications. Studies were reviewed and categorised as representing objectifying, clarifying, or descriptive and/or justifying research.

RESULTS

When students enter clinical training, they need to relearn what they thought they knew and they must learn new things in a more self-directed way. As junior doctors or specialist trainees, their main challenges involve handling the many responsibilities that accompany the delivery of patient care while simultaneously learning from the process of providing that care. As medical specialists, new non-medical tasks and decisions on how to delegate responsibilities become issues.

CONCLUSIONS

Research on transitions has objectified the challenges students and doctors face. Clarifying studies often lack conceptual frameworks that could help us to gain deeper insight into the observed phenomena. Psychology offers valuable theoretical perspectives that are applicable to medical education transitions. To transform a transition from a threat to a learning opportunity, medical education should assist students and doctors in developing the coping skills they need to effectively deal with the challenges presented by new environments.

Medical clerkships do not reduce common prescription errors among medical students

Prescribing correctly represents one of the most essential skills of a doctor when it comes to patient safety. Unfortunately, prescribing errors still account for a large proportion of avoidable drug-related problems (DRP). Despite this shortcoming, many medical schools do not provide specific prescribing training and assume that students acquire sufficient prescribing skills during regular medical clerkships. We therefore investigated whether there is an association between the individual time spent by students in internal-medicine clerkships and the number of prescription errors committed in a standardized prescribing test for common drug-related problems in a medical inpatient setting. Seventy-four fifth-year medical students (25 +/- 3 yrs, 24 m, 50 f) who had completed their formal pharmacology training filled in prescription charts for two standardized patient paper cases. The charts were rated by two blinded consultants from the field of internal medicine using a checklist for common prescription errors. Students were divided into three groups according to the number of weeks previously spent in internal-medicine clerkships. Group differences in the number of prescription errors made were subsequently examined. Students committed 69% +/- 12% of all possible prescription mistakes. There was no significant difference between the group without clerkships in internal medicine (G1) (71 +/- 9%), the group with one to four weeks (G2) (67 +/- 15%), and the group with more than five weeks of clerkships (G3) (71 +/- 10%), p = .76. Medical students do not seem to acquire the necessary skills to avoid common prescription errors during regular clerkships in internal medicine. This study provides evidence to suggest that specific prescription training within medical education is warranted in order to prevent DRP.

Transferring clinical communication skills from the classroom to the clinical environment: perceptions of a group of medical students in the United kingdom

PURPOSE

To better understand the transfer of classroom-learned clinical communication skills (CCS) to the clinical environment of the hospital ward, where they are practiced and refined by students.

METHOD

The author first briefly presents the literature on clinical communication, provides an overview of the debates around the notion of transfer, and presents a sociocultural model of developmental transfer applied to CCS learning. Second, she describes a focus group and nine individual interviews carried out with 17 fourth-year medical students at one medical school in the United Kingdom in 2008. The goal was to elicit their views of CCS teaching, learning, and transfer of CCS to the clinical workplace.

RESULTS

The findings are presented under the four main themes of transition, where students experienced the transition from the medical school to the hospital ward as a mixture of positive and negative impacts on transferring their CCS skills; the clinical culture, where senior doctors had the greatest impact on student learning and emergent clinical practice; clinical communication as a vehicle for professionalism and being a "good" doctor; and, finally, transfer mechanisms, where simulated practice with actors and the clinical history template were powerful learning tools.

CONCLUSIONS

Findings indicate that more needs to be done to support, develop, and embed CCS into the professional practice of medical students in the clinical workplace. This may be achieved by greater collaboration of educators in the academic and clinical environments. Using the developmental transfer model applied to CCS learning may help foster this relationship.

Do educational interventions improve prescribing by medical students and junior doctors? A systematic review

Our aim was to review systematically the literature on educational interventions to improve prescribing by medical students and junior doctors. MEDLINE, EMBASE, Educational Resource Information Center, British Education Index, PsycINFO, CINAHL, TIMELIT, Cochrane Trials Database and grey literature were searched. Inclusion criteria were: educational interventions to improve medical student and/or junior doctors' prescribing, in primary or secondary care settings, and published after 1990. After screening 3189 records, we retrieved 11 controlled and four 'before-and-after' trials. Ten controlled trials showed improvements in the scores of the intervention group on written scenarios or clinical examination stations, but one study in junior doctors showed no effect on real-life prescription errors. Only one intervention [the World Health Organization (WHO) Good Prescribing Guide, in six randomized trials] had been tested in a variety of international settings and across a range of students at different levels. All four 'before-and-after' trials reported significant improvements in written tests or clinical stations. However, most studies tested only small numbers of participants and were affected by a range of methodological flaws. There is only moderate evidence in the literature to inform medical schools about how to prepare medical students for the challenges of prescribing. The WHO Good Prescribing Guide is the only model that has been widely used and shown to improve prescribing. Although it is based on sound principles, there is a need for further development. Robust methods of assessment are required to show clearly whether particular teaching interventions are successful.

Problem-based training for medical students reduces common prescription errors: a randomised controlled trial

CONTEXT

Avoidable drug-related problems (DRPs) cause substantial morbidity, mortality and costs. As most prescription errors are committed by recently graduated doctors, undergraduate training should specifically address DRPs.

OBJECTIVES

This study set out to investigate whether a DRP teaching module can reduce prescription errors made by advanced medical students in varying clinical contexts.

METHODS

A total of 74 Year 5 medical students (mean age 25 +/- 3 years; 24 men, 50 women) participated in a randomised controlled crossover study. Students filled in patients' prescription charts before and after a special DRP training module and a control intervention. The 1-week training module comprised a seminar on common prescription errors, a prescribing exercise with a standardised paper case patient, drafting of inoperative prescription charts for real patients and discussions with a lecturer. During the observation points, prescription charts for standardised patient cases in different clinical contexts had to be completed. These prescription charts were subsequently analysed by two independent raters using a checklist for common prescription errors.

RESULTS

Prior to training, students committed a mean of 69 +/- 12% of the potential prescription errors. This decreased to 29 +/- 15% after DRP training (P < 0.001).

CONCLUSIONS

Prescription errors can be significantly reduced in a relatively brief training time by implementing a specific DRP teaching module.

Centralized assessment in graduate medical education: cents and sensibilities

RATIONALE

The start of residency represents an "educational handoff." Accreditation and credentialing organizations have called for better assessments of learner and patient outcomes and improved patient safety and quality of care.

INTERVENTION

We describe the development of centralized assessments of baseline, core residency competencies at 2 institutions, and summarize principles and lessons learned for other institutions interested in developing similar interventions.

RESULTS

At one institution, 70% of 1 083 new residents assessed via the Objective Standardized Clinical Examination stated they learned a new skill; 80% believe it was a useful way to spend orientation; 78% felt better prepared for aspects of internship; and 80% would recommend it for next year's interns. High levels of satisfaction are expressed by participants at the other institution, especially with the immediate provision of feedback after each station. At this institution, average new resident performance in the communication skills domain approached 90%, but patient care domain scores showed wide variability. The lowest scores were related to performing the psychomotor skills of aseptic technique.

DISCUSSION

From a patient safety perspective, results suggest a need to improve the preparation of new residents, along with careful supervision of their early clinical work. The presence of skill deficits likely adds to the highly stressful transition into residency. Teaching institutions may use centralized assessment to enhance education and patient safety and to promote accountability to accrediting bodies, residents, and patients. The approach may identify gaps in the undergraduate curriculum. The addition of hand hygiene and aseptic technique teaching and assessment modules are currently being piloted at each of the institutions.

[Workplace learning for final-year medical students: a comprehensive analysis of student's expectancies and experiences]

BACKGROUND

The amended German license to practice medicine (AAppO) focuses on practically oriented, patient-centred medical education. After the cancellation of the former medical doctor traineeship "Arzt im Praktikum" (AiP) qualification period in October 2004, the final year of medical education, the so-called "practical year" (PJ), has become a key teaching module in realising the demands of the AAppO. So far no studies have been carried out in the German-speaking area to qualitatively assess the specific needs and central problems that PJ students are facing. The aim of this investigation was to representatively evaluate the expectancies and experiences of final-year medical students in a workplace learning environment.

METHODS

65 students (30 male, 35 female, age 25.4 +/- 2 years) of two German university hospitals participated in focus groups both prior and subsequent (n = 60; drop-out rate 7.7%) to a 4-month period of internal medicine traineeship during their final year. Focus group protocols were transcribed and subjected to content analysis.

RESULTS

1137 individual statements on relevant topics were identified from the transcriptions. Students widely reported lack of time on the part of supervising doctors and exorbitant assignment to routine jobs. This results in insufficient training of independent patient management, followed by feelings of uncertainty and the fear of making medical errors.

CONCLUSIONS

Specific educational strategies and motivation of medical teachers are important factors to the workplace learning environment. A structured curriculum including cognitive, procedural and communicative learning objectives and the introduction of defined time slots for bedside teaching is considered a good first step in this process.

[Working on the ward as part of the medical school curriculum: the influence of final year students on learning outcomes of medical students in their 7th semester and their feeling integrated]

INTRODUCTION

Integrating medical students into their future working environment is of utmost importance in order to ensure a smooth transition from university life to clinical practice. In the German-speaking area, there has so far been no quantitative analysis of the extent or the quality of supervision received by medical students during their ward clerkship during their clinical studies in the specialist field of internal medicine.

METHODS

In the summer of 2005, 161 medical students in their 6th and 7th semester undertook ward clerkships on internal wards at the University Clinic of Heidelberg and its academic hospitals. Using a questionnaire, a survey was conducted among these students about the intensity and quality of supervision received during their work on ward.

RESULTS

Medical students working on the wards of academic hospitals were significantly more frequently co-supervised by senior physicians (p < 0.001), while a higher level of co-supervision by final year students was reported for the University Clinic (p < 0.001). Students supervised by final year students reported greater subjective learning outcomes (p < 0.001). However, this had no effect on the extent to which students felt integrated on the ward.

DISCUSSION

Final year students play a central role in incorporating medical students into the ward routines of teaching hospitals. While they cannot replace instruction or supervision by a qualified physician, the promising potential of "peer-teaching" programmes should be utilized and junior physicians should be systematically prepared for and supervised in this important function.

Preparation for clinical practice: a survey of medical students' and graduates' perceptions of the effectiveness of their medical school curriculum

This paper describes the perceptions of students and graduates of the Hebrew University-Hadassah medical school in Israel regarding the effectiveness of their medical education in preparing them for work in the clinical setting. The six-year curriculum consists of three years of mainly lecture-based Basic Science courses, and three years of clinical education, consisting of clinical clerkship rotations of various lengths. An anonymous questionnaire containing 114 items was distributed to 294 students (in their clinical years) and 500 graduates of the faculty. A total of 371 respondents completed the questionnaire (response rate 49%). Overall 60% of the respondents were generally satisfied with the medical training they received. However, respondents indicated many deficiencies in the curriculum, and in their competences. More than half of the respondents felt that Basic Science courses lacked clinical relevance. Almost 40% of the respondents reported that students were not taught sufficient clinical skills in preparations for clinical practice. At least 50% of the respondents reported that they had not received adequate exposure to 26 out of the 36 important clinical activities and skills during clerkships. Only 33% of the respondents agreed that the fundamental knowledge, skills, attitudes and values that medical students should possess at the time of graduation were made explicitly clear to them. Perspectives of students and graduates were compared. In many questions significantly more graduates tended to rate their learning experience better than students. This study illuminates many aspects of the curriculum the faculty needs to address in order to prepare physicians effectively and efficiently for clinical work. It also stresses the need to integrate better preclinical and clinical studies, and to change to active learning methods. This study demonstrates the necessity of gathering information from students and graduates to evaluate their medical education experience.